CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Minnesota Medicaid

List of services, codes, and instructions for submitting prior authorization requests for UnitedHealthcare Community Plan of Minnesota providers (includes Senior Care Options, Senior Care Plus, Special Needs Basic Care, LTSS). Applies to participating in-network and out-of-network providers for Minnesota Medicaid.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Minnesota Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 877-440-9946.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online, phonesubmission methods for prior authorization

877-440-9946contact points provided

Exemptemergency care

Multiple listsexamples of services requiring prior authorization

~200+codes listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services That Require Prior Authorization

Prior authorization requirement groups

The following services require prior authorization when billed for Minnesota Medicaid members on the UnitedHealthcare Community Plan.

Covered services listed below require prior authorization when billed for Minnesota Medicaid members on the UnitedHealthcare Community Plan.

Service groups

Bariatric surgery (example CPT codes: 43644, 43645, 43659, 43770). Note: Centers of Excellence requirement applies for coverage in certain situations.
Behavioral health services — contact the telephone number on the member's health plan ID card for specific codes and referral/authorization requirements.
Cancer supportive care / chemotherapy / colony-stimulating factors — outpatient injectable colony-stimulating factors and related agents require prior authorization (examples: J2506, J1447, Q5101, Q5110).
Cardiology and cardiovascular procedures — specified cardiovascular intervention CPT codes require prior authorization (examples: 37221, 37227, 37231, 37225, 37229).
Cochlear and other auditory implants (examples: 69710, 69714, 69930, L8614, L8691, L8692) require prior authorization.

Listed services requiring prior authorization

Services and codes in this list require prior authorization.

Durable Medical Equipment (DME) items require prior authorization (examples: A9279, A9280, E0194, E0471, E0483, E0620). Some DME entries note rental cost thresholds.

Enteral services require prior authorization (examples: B9002, B9998).

Gender dysphoria treatments and related surgeries require prior authorization (examples: 14000, 14001, 19303, 55175).

Genetic and molecular testing require prior authorization (examples: 81228, 81229, 81277, 81400, 81401).

Prior authorization requirements (enumerated)

Prior authorization or notification is required for the following categories and listed codes.

Surgical / reconstructive procedures: Specific reconstructive and surgical CPT codes require prior authorization (see listed codes in policy; examples include 14000, 14302, 19303 and multiple other reconstructive procedure codes).

Genetic and molecular testing CPT and temporary codes require prior authorization/notification; ordering providers and laboratories may have notification requirements for some tests (BRCA example: 81432).

Injectable medications and radiopharmaceuticals: A broad list of injectable medications and radiopharmaceuticals require prior authorization; certain products require prior notification via OptumRx (examples include Cimzia, Synagis, Xolair) and many J-/Q-codes are listed in the policy.

Home health care and hysterectomy: Prior authorization is required for listed home health HCPCS/G-codes and for hysterectomy CPT codes included in the policy.

Prior authorization requirement

Listed joint replacement procedures require prior authorization:

Joint replacement codes (examples)

24360
24361
24363
24371
27125
27132

Prior authorization required services (excerpt)

Services listed below require prior authorization before they will be covered or scheduled:

Joint replacement — total hip and knee (example codes: 24361, 24371, 24363, 27125) — prior authorization required.

Musculoskeletal procedures (example codes: 23470, 23472, 23473, 23474) — prior authorization required.

Non-emergent air ambulance transport (HCPCS examples: A0430, A0431, A0435, A0436, S9960, S9961) — prior authorization required.

Orthognathic surgery for maxillofacial/jaw functional impairment (example CPT codes: 21121, 21123, 21125, 21127, 21141–21151) — prior authorization required.

Prior authorization code lists

Codes and categories that require prior authorization as listed below.

Musculoskeletal procedure codes listed in the policy require prior authorization (examples provided in the policy).

Non-emergent air ambulance HCPCS codes listed require prior authorization (examples: A0430, A0431, A0435, A0436, S9960, S9961).

Orthotics and prosthetics codes are listed; prior authorization is required only when retail purchase or cumulative rental cost exceeds $500 (examples: L0112, L0170, L0456, L0462, etc.).

This section contains extensive CPT/HCPCS code lists; consult the full policy for the complete enumerated code lists and specific clinical criteria.

Procedures and services requiring prior authorization (examples listed)

Procedure categories and example CPT/HCPCS codes requiring prior authorization or notification:

Examples by category

Pain management (examples: 62350, 62351, 62360, 62361, 62362) — prior authorization required.
Prostate procedures (examples: 37243, 52441, 52442, 53850, 53852) — prior authorization required.
Radiation therapy (examples: 77520, 77522, 77523, 77525) — prior authorization required.
Rhinoplasty (examples: 30400, 30410, 30420, 30435, 30465) — prior authorization required.
Shoulder and spinal surgery categories include numerous CPT codes listed in the policy and require prior authorization (see full code list).

CPT/HCPCS/ICD Codes and Coding Notes

Covered CPT/HCPCS CodesCPTCovered

81432	BRCA1/BRCA2 full sequence analysis
81163	BRCA1/BRCA2 duplication/deletion analysis (common rearrangements)
81433	BRCA1/BRCA2 targeted sequence analysis, single variant
81164	BRCA1/BRCA2 duplication/deletion single gene analysis
81212	BRCA1, full gene analysis (alternate code grouping)

Covered HCPCS/HCPCS J/Q Codes — Colony-stimulating factors and biosimilarsHCPCSCovered

J2506	Pegfilgrastim (Neulasta)
Q5101	Filgrastim biosimilar (Zarxio)
Q5108	Pegfilgrastim-jmdb (Fulphila) biosimilar
Q5110	Filgrastim-aafi (Nivestym)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5125	Pegfilgrastim-jmdb (alternate biosimilar mapping)
J1442	Filgrastim (Neupogen)
J1447	Tbo-filgrastim

Cardiovascular intervention CPT CodesCPTCovered

37220	Transcatheter embolization, initial vessel
37221	Transcatheter embolization, additional vessel
37222	Transcatheter embolization, peripheral vessel
37223	Transcatheter embolization, visceral vessel
37224	Transcatheter vascular reconstruction
37225	Transcatheter placement of intravascular stent(s)
37226	Transcatheter arterial device removal
37227	Transcatheter embolization, with other device
37228	Transcatheter vascular device placement (other)
37229	Transcatheter recanalization, peripheral artery

1–10 of 12

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What Providers Must Do

Prior Authorization

How to submit prior authorization; emergency care exception; out-of-network requirement

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or by phone at 877-440-9946. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request authorization for all procedures and services except emergent or urgent care.

Online: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal
Phone: 877-440-9946
Emergency/urgent care: prior authorization not required
Out-of-network providers: must request authorization except for emergent/urgent care

Prior Authorization

Cardiology prior authorization contact and program

Cardiology prior authorization requests may be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by calling 866-889-8054; see Minnesota's Cardiology Prior Authorization and Notification Program for the specific CPT codes that require prior authorization.

Definitions and Clarifications

Request approval before rendering a service

DefinitionPrior authorization: Request approval before rendering a service as required by UnitedHealthcare policy.

PurposeAdvance notification provides UnitedHealthcare timely communication and is required under direction of UnitedHealthcare Health Services.

Emergency exceptionPrior authorization is not required for emergency or urgent care.

Prior authorization required for listed services and codes

RequirementPrior authorization is required for the listed services and codes before the service is provided to Minnesota Medicaid members.

ExamplesServices include DME, enteral services, genetic/molecular testing, gender dysphoria surgeries and others enumerated in the policy.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Minnesota Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 877-440-9946.

SourceLink

On This Page

Joint replacement: Total hip and knee replacement CPT codes require prior authorization (see joint replacement code lists in the policy).

Contact Prior Authorization and Notification at 888-397-8129 or submit via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool for joint replacement requests.

Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or call the numbers provided in the policy (e.g., 866-889-8054 or 888-397-8129) to submit prior authorization requests or notifications for these procedure categories.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal
Phone: 866-889-8054
Refer to Minnesota's Cardiology Prior Authorization and Notification Program for code details

Prior Authorization

DME prior authorization requirements

Durable medical equipment (DME) items listed in the policy require prior authorization; several HCPCS codes (e.g., A9279, A9280, E0194, E0265, E0266, E0270, E0277, E0471, E0483, E0620, etc.) are identified and some entries note rental-cost thresholds or that authorization is required only for DME.

Examples of DME codes requiring prior authorization: A9279, A9280, E0194, E0265, E0266, E0270, E0277, E0471
Some DME entries are flagged as required only for DME and reference rental-cost thresholds

Prior Authorization

Enteral services prior authorization

Enteral services (for example, codes B9002 and B9998) require prior authorization before they will be provided.

Enteral service codes requiring prior authorization include B9002 and B9998

Prior Authorization

Surgery and genetic/molecular testing prior authorization

Gender dysphoria–related surgical procedures and genetic/molecular testing require prior authorization; genetic and molecular testing codes (for example 81228, 81229, 81400, 81401, and others) are subject to prior authorization/notification.

Gender dysphoria surgical codes listed (examples include 14000, 19303)
Genetic/molecular testing codes (examples include 81228, 81229, 81400, 81401) require prior authorization/notification

Prior Authorization

Procedures requiring prior authorization (including experimental)

Certain procedures are identified as experimental/investigational or otherwise require prior authorization; femoroacetabular impingement (FAI) arthroscopy codes (29914–29916) are specifically listed as requiring prior authorization.

Examples of experimental/investigational procedures requiring prior authorization: 33477, 36514
FAI arthroscopy codes requiring prior authorization: 29914, 29915, 29916

Prior Authorization

Surgical / reconstructive procedures prior authorization

Providers must obtain prior authorization for the listed surgical and reconstructive CPT codes (including multiple gender dysphoria and reconstructive procedure codes such as 14000, 14302, 15734, 19303, 55175, and others) before performing these services.

Listed surgical/reconstructive CPT examples: 14000, 14302, 15734, 19303, 55175
Prior authorization is required for the full list of surgical/procedure CPT codes included in the policy

Documentation Required

Genetic and molecular testing prior authorization/notification

Genetic and molecular testing CPT and temporary codes require prior authorization or notification; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare prior to DNA sequencing for BRCA testing.

Genetic/molecular testing examples: 81228, 81229, 81400, 81401 and many molecular/temporary codes
BRCA-specific requirement: ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare before DNA sequencing

Prior Authorization

Home health care and hysterectomy prior authorization

Prior authorization is required for home health care services (listed G‑ and S‑/G‑codes such as G0299, G0495, G0300, G0496, G0493, S9474) and for hysterectomy procedures (listed CPT codes including 58150, 58152, 58180, 58260, 58263, 58267, 58270, 58290, etc.).

Home health care codes requiring prior authorization: G0299, G0495, G0300, G0496, G0493, S9474, G0494
Hysterectomy CPT examples requiring prior authorization: 58150, 58152, 58180, 58260, 58263, 58267, 58270, 58290

Prior Authorization

Injectable medications prior authorization and prior notification rules

A large list of injectable medications and radiopharmaceuticals require prior authorization; for certain products (Cimzia, Synagis, Xolair) obtain prior notification via OptumRx prior notifications at 800-310-6826. Some unclassified/temporary codes require authorization only for specific products.

Injectable examples include many J‑ and Q‑codes (e.g., J1745, J2350 and numerous others listed throughout the policy)
Prior notification for Cimzia, Synagis, Xolair: OptumRx prior notifications services at 800-310-6826
Unclassified/temporary codes (e.g., C9090) require authorization only for named products

Prior Authorization

Joint replacement prior authorization

Total joint replacement procedures (total hip and total knee) require prior authorization; examples of listed CPT/HCPCS codes include 24360–24371 series, 27125, 27130, 27132, 27134, 27137–27138, 27412, 27446, 27447, 27486–27487 and J7330.

Joint replacement examples: 24360, 24361, 24363, 27125, 27130, 27132, 27134, 27137, 27138, 27412, 27446, 27447, 27486, 27487, J7330
Contact Prior Authorization and Notification for joint replacements (see policy for portal/phone details)

Prior Authorization

Prior authorization required for joint replacement

Prior authorization and notification are required before performing joint (total hip and knee) replacement procedures; submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or contact Prior Authorization and Notification at 888-397-8129.

Submit via UnitedHealthcare Provider Portal Prior Authorization and Notification
Phone contact for Prior Authorization and Notification: 888-397-8129

Prior Authorization

Joint replacement (total hip and knee) prior authorization

Joint replacement (total hip and knee) requires prior authorization; contact Prior Authorization and Notification at 888-397-8129 or submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Portal submission: Prior Authorization and Notification tool on UHCprovider.com
Phone: 888-397-8129

Prior Authorization

Musculoskeletal procedures prior authorization

Specified musculoskeletal procedures (for example CPT codes 23470, 23472, 23473, 23474) require prior authorization before scheduling or coverage.

Musculoskeletal example codes requiring prior authorization: 23470, 23472, 23473, 23474

Prior Authorization

Non-emergent air ambulance transport prior authorization

Non-emergent air ambulance transport requires prior authorization for the listed HCPCS codes A0430, A0431, A0435, A0436, S9960, and S9961.

Non-emergent air ambulance HCPCS codes requiring prior authorization: A0430, A0431, A0435, A0436, S9960, S9961

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery for treatment of maxillofacial/jaw functional impairment requires prior authorization for the listed CPT codes (examples include 21121, 21123, 21125, 21127, 21141–21151 and additional codes listed).

Orthognathic surgery example codes requiring prior authorization: 21121, 21123, 21125, 21127, 21141–21151

Prior Authorization

Drug prior notification via OptumRx

Obtain prior notification for selected drugs (Cimzia, Synagis, Xolair) via OptumRx prior notifications services at 800-310-6826.

OptumRx prior notifications phone: 800-310-6826
Used for prior notification of Cimzia, Synagis, Xolair

Documentation Required

How to submit prior authorization requests

Authorization requests may be submitted online using the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or by calling 888-397-8129 (or other program-specific phone numbers listed in the policy).

Portal: UHCprovider.com → Sign In → Prior Authorization and Notification
Phone: 888-397-8129 (program-specific numbers such as 866-889-8054 apply for some services)

Prior Authorization

Musculoskeletal prior authorization

Musculoskeletal services listed in the policy require prior authorization before they will be scheduled or covered.

Refer to the musculoskeletal code list in the policy for specific CPT codes requiring prior authorization

Prior Authorization

Non-emergent air ambulance prior authorization

Non-emergent air ambulance transport codes (A0430, A0431, A0435, A0436, S9960, S9961) require prior authorization.

Prior authorization required for non-emergent air ambulance HCPCS codes listed

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery codes for treatment of maxillofacial/jaw functional impairment require prior authorization; the policy lists numerous CPT codes (for example 21121–21127, 21141–21151, 21154–21160, 21188, 21193–21199, 21206, 21208–21210, 21215, 21240–21247, 21255, 21296, 21299, etc.).

Multiple orthognathic CPT codes listed require prior authorization (see policy for full code list)

Prior Authorization

Orthopedic surgeries prior authorization

Orthopedic surgery codes listed in the policy require prior authorization (examples include 24365, 25441–25446, 27700, 29837–29847, 29891–29899 and others).

Representative orthopedic CPT codes requiring prior authorization: 24365, 25441–25446, 27700, 29837–29847, 29891–29899

Prior Authorization

Orthotics and prosthetics prior authorization threshold

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $500; numerous L‑codes are listed in the policy and are subject to this threshold.

Prior authorization threshold: retail purchase or cumulative rental cost > $500
Examples of prosthetic/orthotic codes listed: L0112, L0170, L0456, L0462, L0464, L0480, etc.

Prior Authorization

Obtain prior authorization

Providers must obtain prior authorization for the listed CPT/HCPCS codes and named procedure categories; submit requests through the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054 to obtain prior authorization/submit notification.

Portal: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal
Phone for many programs: 866-889-8054

Prior Authorization

Pain management prior authorization

Pain management procedures (for example CPT codes 62350, 62351, 62360, 62361, 62362) require prior authorization.

Pain management CPT examples: 62350, 62351, 62360, 62361, 62362

Prior Authorization

Rhinoplasty

Rhinoplasty procedure codes (examples include 30400, 30410, 30420, 30435, 30465, 30450, 30460, 30462) require prior authorization.

Rhinoplasty CPT examples requiring prior authorization: 30400, 30410, 30420, 30435, 30465, 30450, 30460, 30462

Provider actionSubmit authorization requests via the Provider Portal or by calling the specified phone numbers prior to service delivery.

BRCA testing notification

RequirementNotification/prior authorization is required for BRCA testing before DNA sequencing is performed; ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Applies toBRCA and related molecular genetic tests referenced in the genetic testing section.

Related processLabs are expected to notify UnitedHealthcare as part of the prior authorization/notification workflow for these tests.

Unclassified Codes (e.g., C9090, C9149, C9157, J3490)

DefinitionUnclassified/temporary codes (examples): C9090, C9149, C9157, J3490 are listed as unclassified codes requiring prior authorization in some cases.

ContextThese codes appear in the injectable medications/therapeutics lists and may require authorization for specific products.

Provider noteCheck the policy's unclassified code entries for product-specific prior authorization requirements.

Prior authorization required before performing listed joint replacement procedures

RequirementPrior authorization is required before performing listed joint replacement procedures (total hip and knee).

ContactFor joint replacement prior authorization, contact Prior Authorization and Notification at 888-397-8129 or submit via the Provider Portal Prior Authorization and Notification tool.

Example codesExamples listed include 24361, 24371, 24363, 27125 and other joint replacement CPT/HCPCS codes.

Prior Authorization and Notification (portal)

Portal toolUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com -> Sign In -> Prior Authorization and Notification).

Phone optionsGeneral prior authorization phone: 877-440-9946; alternative contact for some programs: 866-889-8054; joint replacement: 888-397-8129.

How to access portalSign in with One Healthcare ID; if you don't have one, visit UHCprovider.com/access to register.

OptumRx prior notifications services

OptumRx prior notificationsFor certain medications (for example Cimzia, Synagis, Xolair), obtain prior notification via OptumRx prior notifications services at 800-310-6826.

When to useUse OptumRx prior notifications for specified injectable drugs that require prior notification rather than standard portal submission.

Related guidanceJoint replacement and other program guidance also reference OptumRx for select products in the injectable medication lists.

Orthotics/prosthetics prior authorization threshold

ThresholdPrior authorization is required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500.

ExamplesListed HCPCS examples include L0112, L0170, L0456 and many other L-codes in the orthotics/prosthetics section.

Provider actionObtain prior authorization when item retail purchase or cumulative rental cost exceeds $500 before scheduling or billing.

Prior authorization requirement

RequirementPrior authorization is required for the listed musculoskeletal, non-emergent air ambulance, orthognathic and orthopedic procedure codes.

ExamplesMusculoskeletal CPT examples: 23470, 23472, 23473, 23474; Air ambulance HCPCS: A0430, A0431, A0435, A0436, S9960, S9961.

Provider actionSubmit prior authorization via the Provider Portal or call the designated phone numbers before scheduling these services.

Prior authorization and Notification tool on the UnitedHealthcare Provider Portal (or phone 866-889-8054)

Portal/phoneUse the Prior Authorization and Notification tool on UHCprovider.com or call 888-397-8129 (joint replacement) or 877-440-9946 (general).

Alternate phoneFor some programs (radiology advanced outpatient imaging), call 866-889-8054 as an alternative to the portal.

ProcedureSelect Prior Authorization and Notification on the portal dashboard after signing in with your One Healthcare ID.